Student: Early-elementary-age student;
Assignment: Dedicated one-to-one registered nursing support
Assignment summary
This is a high-acuity one-to-one registered nursing assignment centered on airway protection and respiratory stability. The RN should expect very frequent suctioning, frequent oxygen-saturation assessment, oxygen administration under current orders, management of an open tracheostomy stoma, respiratory treatments, G-tube feeding, seizure readiness, skin and mobility support, detailed documentation, and immediate response to potentially rapid respiratory deterioration.
Primary daily needs: Airway and open-stoma management, very frequent suctioning, oxygen-saturation monitoring, oxygen administration, respiratory assessment, G-tube feeding, medication/treatment administration, seizure readiness, skin care, positioning, and emergency response
Expected daily RN responsibilities
| Care responsibility | Expected frequency | What the RN should expect | Arrival assessment | At arrival and with every change | Establish respiratory and neurological baseline: color, alertness, work of breathing, airway sounds, cough effectiveness, secretions, stoma condition, oxygen saturation, lung sounds, gag/airway protection, G-tube site, skin, seizure concerns, and equipment readiness.
| Oxygen saturation monitoring | Frequent daytime spot checks; continuous monitoring during sleep unless orders require more | Available pulmonary guidance recommends frequent daytime checks and continuous oximetry during sleep. Document baseline, trends, events, interventions, and response.
| Oxygen administration | During sleep and as needed under current order | The available record describes oxygen at 2 L/min by nasal cannula during sleep and supplemental oxygen as needed to maintain saturation above the provider's target. Confirm current flow, target, equipment, and escalation parameters.
| Airway/stoma care | Throughout the day and as needed | Assess the open tracheostomy stoma and surrounding skin; monitor air exchange and secretions; maintain cleanliness and ordered dressing/protection; recognize infection, bleeding, obstruction, increased secretions, or change from baseline.
| Suctioning | Very frequent and as clinically indicated | Suction the mouth and around the open stoma using the ordered technique. Assess secretion amount, color, thickness, odor, cough effectiveness, tolerance, oxygen saturation, and respiratory response before and after suctioning.
| Respiratory assessment | Continuous readiness; focused assessment with events | Assess episodes of pallor, cyanosis, apnea, labored or abdominal breathing, noisy/junky lungs, coughing, impaired secretion clearance, or unexplained desaturation; determine intervention and need for EMS or provider contact.
| Respiratory medication/treatment | As ordered | Available records list inhaled corticosteroid therapy and PRN bronchodilator treatment. Confirm which medications/treatments are required during school, the route/device, timing, indications, response monitoring, and emergency parameters.
| G-tube feeding | Approximately every 4 hours; school record lists scheduled feedings | Provide exclusive G-tube nutrition and hydration according to the current order. Verify formula, volume, pump rate, times, water flushes, positioning, tolerance parameters, and response to vomiting or respiratory change.
| G-tube site care | Before feedings and whenever drainage is present | Assess for leakage, redness, skin breakdown, irritation, foul odor, discolored drainage, granulation tissue, pain, or device problems; cleanse/dress as ordered and notify family/provider when indicated.
| Seizure monitoring | Throughout the day and during unusual events | Clarify typical seizure presentation and emergency plan. Assess events involving color change, apnea, altered responsiveness, abnormal movement, or suspected seizure; protect airway, time event, intervene, document, and escalate as ordered.
| Positioning, mobility, and personal care | Throughout the day | Support safe positioning, transfers, diapering, skin care, splints/orthotics, adaptive seating and mobility while monitoring respiratory tolerance, tube/stoma safety, and skin integrity.
| Documentation and coordination | After procedures and any clinical change | Record assessments, saturation readings, oxygen, suctioning, secretions, respiratory treatments, feedings, G-tube/stoma/skin findings, seizures, interventions, response, and communications with family, providers, school staff, and EMS.
Likely daily workflow
· Before arrival: inspect and test the pulse oximeter, oxygen system, suction machine, catheters, emergency equipment, G-tube supplies, respiratory-treatment equipment, and medications; confirm backup power and supplies.
· At arrival: obtain caregiver report and complete a documented respiratory, neurological, airway/stoma, skin, and G-tube baseline assessment.
· Throughout the day: remain with or immediately available to the student; perform frequent saturation checks; suction as needed; reassess after all interventions; and monitor sleep, activity, feeding, and positioning for respiratory effects.
· At scheduled feeding/treatment times: administer ordered G-tube nutrition, water, inhaled medication, or other treatment; monitor closely for intolerance, aspiration, desaturation, or increased secretions.
· Before dismissal: ensure the student is stable for transport, emergency medication/equipment accompanies the student as required, documentation is complete, and responsibility is transferred using the approved handoff plan.
Emergency situations the RN must be prepared to manage
· Oxygen saturation below the student's ordered threshold or a significant unexplained drop from baseline.
· Apnea, ineffective breathing, cyanosis, pallor, altered responsiveness, severe retractions, or inability to clear secretions.
· Acute mucus plugging, increased or foul secretions, bleeding, obstruction, or other complication involving the open stoma.
· Failure to respond to suctioning, positioning, prescribed oxygen, or ordered bronchodilator treatment.
· Vomiting or reflux during G-tube feeding with possible aspiration or respiratory compromise.
· Suspected seizure accompanied by apnea, color change, prolonged altered responsiveness, or failure to return to baseline.
· G-tube dislodgement, blockage, significant leakage, foul drainage, bleeding, skin breakdown, or inability to deliver ordered nutrition/hydration.
Transportation and school-activity expectations
The transportation arrangement must be confirmed. Given the student's unpredictable desaturation, frequent suctioning, open stoma, limited communication, and need for immediate respiratory assessment, the RN may be required during transportation and all school-related activities unless the finalized medical and educational plans provide another safe arrangement.
· Portable suction, oxygen, pulse oximetry, emergency medications, G-tube supplies, and other ordered equipment must remain accessible and secured.
· The plan must identify who monitors the student, who performs suctioning and oxygen administration, when the vehicle stops, and when EMS is activated.
· Emergency handoff procedures must cover pickup, drop-off, delays, field trips, evacuation, and loss of power or equipment function.
